Canada Communicable Disease Report

Final Report of Outcomes from the National Consensus Conference for Vaccine-Preventable Diseases in Canada

June 2005

Executive Summary

The National Consensus Conference for Vaccine-Preventable Diseases in Canada (NCC-VPD), which took place in Quebec City, Quebec, June 12-14, 2005, was the first in a series of consensus conferences that will review disease reduction goals and immunization coverage targets for all VPDs. Establishing national goals and objectives for immunization programs was identified as one of key components of the National Immunization Strategy (NIS). The NIS was endorsed by F/P/T governments in 2003 following a $45 million dollar (Cdn) funding commitment from the federal government to support a collaborative process to address the challenges facing immunization and to improve the effectiveness and efficiency of immunization programs in Canada. The Canadian Immunization Committee (CIC) was established to coordinate this process and improve program planning in support of the NIS.

The purpose of the 2005 consensus conference was to:

• Review existing goals and targets from previous consensus conferences (post 1990) and where necessary, agree upon new national goals and recommendations for disease reduction and immunization coverage for the following six diseases: meningococcal disease (IMD), pneumococcal disease (IPD), varicella, pertussis, influenza and rubella.
• Achieve consensus on the goals and recommendations; and
• Outline the essential steps to facilitate national adoption and implementation of the goals and recommendations.

The CIC recommended six VPDs for review in this first consensus conference. Four diseases, invasive meningococcal disease (IMD), invasive pneumococcal disease (IPD), pertussis and varicella were selected as public funding, in the amount of $300 million dollars (Cdn), was given to provinces and territories by the federal government for the purchase of vaccines after the approval of the NIS in 2004. Rubella was included in support of the Pan-American Health Organization (PAHO) regional goal for indigenous rubella and congenital rubella syndrome (CRS) elimination in the Americas⁽²⁾. Influenza was included as it was thought to be timely.

Conference delegates included representatives from national, international, federal, non-governmental, professional and provincial and territorial agencies and organizations. During the 2-day conference participants were divided into disease specific working groups to review current evidence, identify key issues and develop national goals and recommendations for disease reduction and immunization coverage targets. Recommendations along with rationales were presented in plenary and all conference participants were given the opportunity to vote on each, with the option of "agreeing", "agreeing with reservation" or "disagreeing" with the proposed statement. To achieve consensus a combined vote of 75% either agreeing or agreeing with reservation was required.

Consensus was reached on three overall goals and 52 recommendations. Goals were either not presented or agreed upon for varicella, IMD and pertussis, however, goals were proposed by CIC following the conference and are included in this report. For influenza, it was agreed, by consensus, to adopt the 2001 national immunization coverage targets⁽³⁾ and to postpone the development of recommendations for disease reduction for a future conference.

Conference participants stressed the importance of maintaining the momentum gained at the conference, specifically, ensuring that the goals and recommendations proceed expeditiously through the Pan-Canadian Public Health Network. It was further suggested that a review of provincial/territorial infrastructure be undertaken to identify needs and gaps related to the implementation of recommended goals and recommendations. These were assessed in a post conference survey of the provinces and territories⁽³⁾.

The CIC will review the recommendations resulting from the 2005 NCC-VPD and work with a task group to consolidate conference proceedings. Recommendations will be forwarded on for endorsement by the Pan-Canadian Public Health Network to the Conference of F/P/T Deputy Ministers of Health.

Future consensus conferences are planned to review, develop and update national goals and recommendations for immunization coverage and disease reduction for all VPDs.

Introduction

From June 12-14, 2005, a cross section of Canada's scientific, public health and medical communities gathered in Quebec City, Quebec for the 2005 National Consensus Conference for Vaccine-Preventable Diseases in Canada (NCC-VPD). The purpose of the conference was to achieve consensus on national immunization coverage and disease reduction goals and targets for six vaccine-preventable diseases (VPDs) (rubella, varicella, invasive pneumococcal disease (IPD), invasive meningococcal disease (IMD), influenza and pertussis) and to identify the process for their adoption and implementation at the national level.

Welcome

(Dr. Ian Gemmill, Chair of the Conference Planning Committee and Dr. Horacio Arruda, Representative of the Ministre de la Santé et des Services sociaux du Québec)

The speakers acknowledged the number of sectors involved and the importance of consensus forums in developing, delivering and evaluating immunization policies and programs; a theme borne out in the introductory presentations highlighted below.

Immunization strategy in Canada:

(Dr. Arlene King, Conference co-chair)

Dr. King presented on 10 years of progress and the status of national recommendations from previous consensus conferences for the six VPDs under review. She also presented the results from a survey to demonstrate jurisdictional uptake of national recommendations into provincial/territorial goals and objectives since 2001. The last time national goals for VPDs were looked at holistically was in 1993 when influenza, IMD, pertussis and other VPDs were reviewed (pertussis was reviewed again in 2002); disease specific conferences for rubella (1994), IPD (1998), and varicella (1999) took place later. However, to this day the measles elimination goal (1995) is the only fully adopted national goal for vaccine-preventable diseases.

In 2001, and again in 2005 jurisdictions were surveyed to determine the uptake of national consensus recommendations. This information was provided to the expert working groups to review along side existing national goals and recommendations prior to this conference and can be found in the discussion guides for each of the six VPDs in Appendix B.

Setting national goals:

(Dr. Richard Massé, Conference co-chair)

Dr. Massé presented some of the challenges and the role of the Ministry of Health in developing and implementing goals and objectives at the provincial level. Initiatives under Quebec public health program, were presented. His presentation focused on the role of the Quebec Immunization Committee which is responsible for improving the quality of immunization programs and capacity for immunization research and evaluation in Quebec. Quebec has substantial experience in developing and implementing public health goals. Some of the challenges include ensuring public and professional involvement in decision-making and securing the necessary funding to enable successful implementation. These challenges must be overcome to make public health goals a reality.

Immunization goals in the United States:

(Dr. Jane Seward, Centers for Disease Control and Prevention (CDC))

Dr. Seward presented the United States' (US) experience developing and implementing national goals. The Healthy People 2010 Strategy⁽⁴⁾, a CDC-led initiative, has set national goals for public health. Immunization and the control of infectious diseases are among the priorities identified in the strategy. Within these priority areas, specific goals have been established for diseases preventable through universal and targeted immunization programs, infectious diseases and emerging antimicrobial resistance, immunization coverage and strategies, and vaccine safety. Dr. Seward concluded with an update on the tracking and implementation of the goals and objectives in each of these categories.

Conference Process

(Dr. Ian Gemmill)

The 2005 Consensus Conference is the first in a series of consensus conferences which will develop national goals and recommendations for disease reduction and immunization coverage in Canada for all VPDs. The CIC, which oversees the implementation of the NIS, approved of and determined the focus and parameters of the conference.

Conference process

The conference took place over 2 days. Following introductory remarks and presentations on the first day, participants remained in plenary session to consider and vote on recommendations for rubella elimination. Participants then spent the rest of day-one in their assigned disease-specific working groups. Presentations on surveillance, epidemiology, laboratory issues and immunization programs and coverage were given in each group. Led by a chairperson and assisted by subject-matter experts, a rapporteur and a note-taker, working group members reviewed disease-specific evidence, identified key issues, and developed and provided rationales for all recommendations.

On the second day, recommendations from the working groups from the five remaining diseases were presented in plenary by panels selected by each disease-specific working group. After presenting the recommendations and rationales, participants asked questions for clarification and then voted using an electronic voting system provided by the National Microbiology Laboratory (NML) in accordance with the rules outlined below. Once the initial level of agreement was determined, the floor was opened for comment and discussion. If consensus was not achieved in the first vote or achieved through a minority vote, a second vote was held after the comment and discussion period.

For the purpose of conference deliberations, the definition of terms is as follows:

Goal: Is defined as a broad statement of a desired achievement over a specific time frame. Goals are not required to be quantitative or measurable.

Objectives/recommendations: Are statements of intent that are specific, measurable, achievable, realistic, and timed. An objective may include a target.

At a subsequent meeting of the CIC, it was recommended that the term objective be reserved for use by the jurisdictions to determine individually how best to work towards nationally agreed upon goals, in a feasible timeframe, given their own unique requirements. Therefore throughout these documents the term objective has been replaced with recommendation.

Targets: Are measurable: they specify the amount of progress to be made and the time by which it is to be made.

Further, time lines for national goals and recommendations should be reasonable and feasible, with 5 years suggested as an appropriate planning horizon.

Vaccine eligibility: For the purpose of developing recommendations for national goals, participants agreed that vaccine eligibility should be based on NACI recommendations rather than jurisdictional public health programs.

Adoption and implementation

(Dr. Greg Hammond)

All consensus goals and recommendations will be moved through the CIC and the new Pan-Canadian Public Health Network. Within this network CIC functions as an "Issue Group" and makes recommendations to the Communicable Disease Control Expert Group (CDCEG), formerly the Communicable Disease Control Network (CDCN), which functions as an "Expert Group". In turn, the CDCEG makes recommendations to the F/P/T Council, which is accountable to the F/P/T Conference of Deputy Ministers of Health. A governing body with a strategic perspective on health, the Conference of Deputy Ministers of Health determines final outcomes on all matters under its consideration.

Consensus development and voting

(Dr. Richard Massé)

The process for voting on consensus recommendations was supported by the assurance that all participants would have an opportunity to express their views in either plenary or working group sessions.

• Options for voting include "agree", "agree with reservations" and "disagree".
• At least 66% of participants eligible to vote must be present to have quorum.
• Consensus was achieved when at least 75% of participants eligible to vote either "agreed" or "agreed with reservations" to a recommendation. The election of a recommendation with 50% to 74% of eligible participants agreeing without reservation constituted a majority vote, while a vote achieving consensus with only 25% to 49% agreeing without reservation represented a minority vote.
• A recommendation was not considered supported if the combined number of participants "agreeing" or "agreeing with reservation" represented < 75% of eligible participants or if > 33% of eligible participants were absent from or declined to take part in a vote.

Participants with voting rights included: provincial/territorial representatives including chief medical officers of health, epidemiologists, and program experts; experts from IRID and the NML; CIC members not functioning in an alternate role; members of the conference planning committee; representatives of non-governmental organizations and health professional associations; and conference co-chairs (in situations where results would be otherwise inconclusive). Voting rights did not extend to international experts, PHAC staff working as rapporteurs and conference support, industry representatives, or participants with a conflict of interest.